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The No Code

The Man Down call goes out. Dispatch is told that the patient is not breathing. Enroute to the call you get a few more details- and it’s a code. Running through your mind- spineboard, gurney, medic bag, drug box, monitor, intubation roll. Ready when you pull up, jump out, get it rocking and "Reality"- the family is on scene, with a Do Not Resuscitate document, but someone panicked and called 911 when the patient went down.

Real Field Problem

The delicacy with which to begin a code arrest protocol where a person has expressed the desire NOT to have any lifesaving measures cannot be understated. Some jurisdictions require that CPR is initiated while the base hospital is called, others require the initiation of a full ACLS protocol until it is determined the document is valid.

I have been personally ordered to "get away from daddy" by a screaming family member, but I had a duty to respond, a duty to do what I have been trained in accordance with the jurisdictional requirements and the base hospital’s orders. Not a fun scenario. Alternatively, I have had a family member "revoke" the DNR and "do everything you can to save him." Again, not a good time.

Because the alternative to beginning CPR and ALCS protocols is irreparable harm to the patient (he dies), this becomes a sticky situation- whose decision is it? Can the family override the patient’s decision? And what is a "valid" document? What are you reading/describing to the base hospital over the radio or phone to get the doctor to make a determination?

The law presumes that an unconscious person wants lifesaving medical care. (1)

This presumption goes to the consent to provide care. For an unconscious patient who cannot consent to anything, the law steps in and presumes that person would want efforts to preserve his life. 50 years ago or so, there was little if any field treatment for codes, and CPR/ACLS and other protocols were non-existent.

"In the 1960s, CPR was initially performed by anesthesiologists on adults and children who suffered from witnessed cardiac arrest following reversible illnesses and injuries. Based on the success of this intervention, CPR became the standard of care for all etiologies of cardiopulmonary arrest and the universal presumptive consent to resuscitation evolved (Burns et al., 2003)." (2)

The advancements in technology and treatment protocols have given rise to the ethical dilemma surrounding Do Not Resuscitate orders in the field. Most of the time, where a valid DNR exists and the family or center knows about it, then the patient dies without intervention, and no one is dispatched to the scene. It is the scenario described above that lands emergency providers smack dab in the middle of starting care, perhaps against the patient’s wishes, because he is unable to advocate for himself.

Here is an excellent FAQ page, provided by the New York State Department of Health.

When you are presented with any Do Not Resuscitate Order

The DNR is the exception to the default rule, which is why it requires legal determination that the documents are valid. Because the law presumes the patient wants lifesaving treatment, and the patient can’t communicate his wishes while he is unconscious, anything that will change the default rule must be in writing, signed and (likely) certified original or true copy, depending on your jurisdiction. Absent a valid order, responders are obligated to perform lifesaving protocols, and treat the patient to the fullest extent of your level of certification or licensure. Know your jurisdictional SOPs, and Base Hospital standing orders!

What about "slow codes" or "show codes"?

"Slow codes and show codes are forms of "symbolic resuscitation." A "slow code" is an act performed by the health care providers that resembles CPR yet is not the full effort of resuscitation while a "show code" is a short and vigorous resuscitation performed to benefit the family while minimizing harm to the patient (Frader et al., 2010). Slow and show codes are ethically problematic. In general, performing slow and show codes undermines the rights of patients to be involved in clinical decisions, is deceptive, and violates the trust that patients have in health care providers. (3)"

What you can do to Inform your agency

1. Recognize your jurisdiction’s order. Take a moment during April to look at your jurisdiction’s DNR paperwork.
The links to State Specific DNR information and forms can be found here (scroll past the company info).
Please remember, there is a federal form from the VA.

2. Make sure the base hospital protocols are understood and complied with anytime this situation arises.

3. Document, Document, Document- what you did on scene for the patient

4. Have backup. An officer may be required to calm family members, contact a bereavement team or wait for the coroner. Remember that the living family members become your patient if the code is called, you have to be ready to "treat" them.